LAPAROSCOPIC APPENDICECTOMY: RISK FACTORS FOR CONVERSION TO LAPAROTOMY

ABSTRACT BACKGROUND: Laparoscopic appendectomy is the gold standard surgical procedure currently performed for acute appendicitis. The conversion rate is one of the main factors used to measure laparoscopic competence, being important to avoid wasting time in a laparoscopic procedure and proceed directly to open surgery. AIMS: To identify the main preoperative parameters associated with a higher risk of conversion in order to determine the surgical method indicated for each patient. METHODS: Retrospective study of patients admitted with acute appendicitis who underwent laparoscopic appendectomy. A total of 725 patients were included, of which 121 (16.7%) were converted to laparotomy. RESULTS: The signiﬁcant factors that predicted conversion, identified by univariate and multivariate analysis, were: the presence of comorbidities (OR 3.1; 95%CI; p<0.029), appendicular perforation (OR 5.1; 95%CI; p<0.003), retrocecal appendix (OR 5.0; 95%CI; p<0.004), gangrenous appendix, presence of appendicular abscess (OR 3.6; 95%CI; p<0.023) and the presence of difficult dissection (OR 9.2; 95%CI; p<0.008). CONCLUSIONS: Laparoscopic appendectomy is a safe procedure to treat acute appendicitis. It is a minimally invasive surgery and has many advantages. Preoperatively, it is possible to identify predictive factors for conversion to laparotomy, and the ability to identify these reasons can aid surgeons in selecting patients who would beneﬁt from a primary open appendectomy.


A QUEDA DA PRESSÃO PORTAL APÓS DESVASCULARIZAÇÃO ESOFAGOGÁSTRICA E ESPLENECTOMIA INFLUENCIA A VARIAÇÃO DO CALIBRE DAS VARIZES E AS TAXAS DE RESSANGRAMENTO NA ESQUISTOSSOMOSE NO SEGUIMENTO EM LONGO PRAZO?
Does the drop in portal pressure after esophagogastric devascularization and splenectomy variation of variceal calibers and the rebleeding rates in schistosomiasis in late follow-up?
Walter de Biase SILVA-NETO 1 , Claudemiro QUIRESE 1 , Eduardo Guimarães Horneaux de MOURA 2 , Fabricio Ferreira COELHO 3 , Paulo HERMAN 3 ABSTRACT -Background: The treatment of choice for patients with schistosomiasis with previous episode of varices is bleeding esophagogastric devascularization and splenectomy (EGDS) in association with postoperative endoscopic therapy. However, studies have shown varices recurrence especially after long-term follow-up. Aim: To assess the impact on behavior of esophageal varices and bleeding recurrence after post-operative endoscopic treatment of patients submitted to EGDS. Methods: Thirty-six patients submitted to EGDS portal pressure drop, more or less than 30%, and compared with the behavior of esophageal varices and the rate of bleeding recurrence. Results late post-operative varices caliber when compared the pre-operative data was observed despite an increase in diameter during follow-up that was controlled by endoscopic therapy. Conclusion variceal calibers when comparing pre-operative and early or late post-operative diameters. The comparison between the portal pressure drop and the rebleeding rates was also not

Perspectives
Laparoscopic appendectomy is a safe procedure to treat acute appendicitis. It is a minimally invasive surgery and has many advantages. Preoperatively, it is possible to identify predictive factors for conversion to laparotomy, and the ability to identify these reasons can aid surgeons in selecting patients who would benefit from a primary open appendectomy.

Central Message
Many studies have confirmed that the laparoscopic approach is a mainstream technique in acute appendicitis. However, complicated appendicitis is considered a dilemma in their management regarding the greater demand for a high-quality experience and the fear of postoperative septic complications. A decision on which approach should be performed must be subject to preoperative criteria.

17%
successful LA converted LA LA: laparoscopic appendectomy. Figure 1. Overall laparoscopic appendectomy conversion rate and successfully converted laparoscopic rate.
The technique of laparoscopic appendectomy LA was performed using a 3-trocar approach (umbilical, 10 mm port; suprapubic, 5 mm port; and lower-left quadrant, 10 mm port), in the Trendelenburg position.
The appendix was extracted through the lower-left quadrant trocar in a plastic bag or through the trocar when removed, depending on the operator preference.
The technique of OA was performed via Mc-Burney's incision or midline incision.

RESULTS
The study enrolled 725 patients who underwent LA. Demographic, clinical, and pathological data of the patients included in the analysis are summarized in Tables 1 and 2.
A total of 604 (83.3%) procedures were successfully performed using the laparoscopic approach while 121 (16.7%) were converted to the open approach ( Figure 1). The mean age was 35.2±16 years with a range from 15-80 years. LA patients were significantly younger than the OA (34±14 vs 48±16), which is statistically significant (p<0.01).

INTRODUCTION
O pen appendectomy (OA) was considered the standard approach for acute appendicitis for a long time 7,10 . Laparoscopic appendectomy (LA) was reported for the first time in 1983, and since then it has been adopted as the gold standard for the treatment of acute appendicitis 4,9,15 . For quite some time, its advantages have been evaluated by some authors in systematic reviews or meta-analysis 15,16 . Many studies confirmed that the laparoscopic approach is a mainstream technique in acute appendicitis 3,7 . However, complicated appendicitis is considered a dilemma in their management regarding the greater demand for a high-quality experience and the fear of postoperative septic complications 15,16 . But the LA approach is moreover used in complicated patterns and rates of conversion to OA varies from 1 to 10% 6 . Therefore, conversion to OA may be the best solution in these cases 15 . A decision on which approach should be performed must be subject to preoperative criteria 1,10 .
We aimed to evaluate the predictors of conversion from LA to OA through a retrospective study highlighting whether patients' characteristics and surgeons' prior experience could impact the conversion.

METHODS
From January 2010 to December 2020, appendectomy for acute appendicitis was performed on 853 patients in the Surgical Department at Habib Thameur Hospital in Tunis, Tunisia. Of these, 725 (84.9%) underwent LA. The clinical, demographic, surgical, and pathological data of these patients were included in a prospective database and were retrieved from our hospital. To record, only LA were considered in the analysis.
The following factors were analyzed to determine which ones were related to the conversion from LA to OA: age, sex, body mass index (BMI), previous abdominal surgery, comorbidities, clinical and laboratory parameters including Alvarado score 1 , preoperative C-reactive protein (CRP), intraoperative findings such as anatomy and degree of inflammation.
During the study period, LA were performed by different surgeons both resident and attending surgeons. The decision to convert to an open procedure was made personally by the surgeon.

Inclusion criteria
The inclusion criteria were: all adult patients older than 14 years of age, admitted with acute appendicitis and who underwent LA.

Exclusion criteria
The exclusion criteria were: patients with missing data, incomplete records, those who underwent two simultaneous procedures, and direct OA cases.

Statistical analysis
All data were assessed with the Statistical Package for Social Sciences (SPSS) software (version 25.0). Multivariate analysis was performed with logistic regression. Two-sided p-values <0.05 were considered statistically significant. The qualitative variables were expressed by their percentages, the quantitative variables by the mean, and by standard deviation (±SD) when the distribution was Gaussian, otherwise, by the median, interquartile, and extremes. Once the data analyzed were from the hospital database, prior approval of the Institution's Ethics Committee was waived.  LA was completed without conversion in 147 male patients and 457 female patients. The ratio of females to males is almost 2.6.
On comparing the clinical presentation of appendicitis, fever was the most common symptom, followed by vomiting and diarrhea in both groups. Symptoms of diffuse tenderness, rebound tenderness, localized guarding, and diffuse guarding were found to be significantly associated with conversion appendicectomy.
The preoperative CRP was higher in the OA group (162.59±100.4) with p<0.001, which is statistically significant. The present study highlights that significantly elevated CRP is also an independent risk factor for conversion from LA to OA.
The computed tomography (CT) scan findings showed that the presence of significant fat stranding, free fluid or free air, abscess formation, and CT grade of 4-5 significantly increased the possibility of conversion; in our study, we found that 68 patients were converted due to the presence of an abscess.
Other reasons justified the conversion, such as difficulty to identify the appendix, uncontrolled bleeding, impossibility to maintain an adequate pneumoperitoneum, and hypotension due to the Trendelenburg's position.
The univariate analysis of factors related to conversion is shown in Tables 3 and 4, concluding that diffuse tenderness is a significant predictive factor for the conversion.
A multivariate analysis (

DISCUSSION
Since its initial description by Kurt Karl Stephan Semm, many other studies had encouraged LA over OA, due to its advantages 12,15 . LA leads to lower postoperative pain, shorter postoperative hospital stay, conducting to a reduced recovery time 7,11,14,15 .
Conversion rate is one of the main factors used to measure laparoscopic competence 5 . The rate of conversion evaluated by many studies was related to various factors and was more associated with higher hospital costs 10 . The main goal of this study was to develop a clinical tool that enables surgeons to estimate the risk of conversion from AL to OA based on objective and easily available preoperative patient parameters.     Almost all studies on the conversion rate from LA to OA affirmed a rate of 9-12% 8,13 .
The conversion rate of 16.7% in this current work is almost identical to the literature's results. We concluded that multiple factors related to patients' characteristics may influence LA conversion to OA 12 such as advanced age (≥65) 10,12 ; patients older than 65 years were associated with higher conversion rate (33.3%) compared to <65 years-old patients (8.9%), (p-value 0.002) 10 . In our study, advanced age was associated with a higher rate of conversion (p-value 0.001) as well.
Other studies demonstrated that males and old age were significant independent factors predicting conversion to OA 4 . Male patients consulting for right lower abdominal pain were more associated with perforated appendicitis, thereby they had the highest-level conversion 2,11,12 .
The majority of patients (96.7%) who underwent laparoscopic conversion recorded in this study, had no previous abdominal surgery. However, the most common reason of conversion was a severe inflammation causing difficult and unsafe dissection. Delayed presentation of appendicitis is also associated with a higher risk of conversion to OA 4 .
On physical examination, diffuse tenderness carried a high risk of conversion to OA (9.92%; p<0.009) 11 , whereas in CT scan, severe inflammation was considered to be an independent predictor of conversion 4 .
The CT scan grade of 4-5 is an important predictor factor of conversion 10 . In our study, the Alvarado score 1 is significantly associated with a higher rate of conversion (p<0.0025).
The CRP is a good marker of severe inflammation which could be a significant risk factor for conversion to OA. A higher value of CRP is associated with severe located inflammatory reaction with increased risk of bleeding, adhesion with the surrounding tissue, and complicated appendicitis 4 .
According to the receiver operating characteristic (ROC) analysis of Aydın et al. 2 , a CRP value of 108.5 mg/L was a risk factor for the conversion to OA. Shimoda et al. 13 concluded that preoperative CRP of >100 and >150 mg/L were a statistically significant predictor for conversion.
Increased value of white blood cell (WBC) count >15000 cells/ cumm was seen to be more associated with conversion to OA, but it is not a statistical independent factor related to conversion 2 . Aydın et al. indicated that a neutrophil ratio of 81.5% was a significant predictive factor of a higher rate conversion because it concludes to bacterial translocation leading to diffuse peritonitis and intraabdominal abscess development 2 .
The preoperative findings such as severe inflammation, gangrenous and perforated appendicitis are the major factors impacting the operative difficulties and associated with conversion to OA 6,8,13 .
Wei et al. 14 concluded to higher conversion rate due to less surgeon experience. Inexperienced surgeons couldn't handle the intraoperative difficulties leading usually to conversion to OA 12 . Liu et al. 10 have confirmed this relationship between the higher rate of conversion (31.3%) and the inexperienced surgeons (≤10 LA performed). However, in the present study, there was no difference in the overall conversion rate between experienced surgeons and resident surgeons, which can be explained by their good initial learning curve.
The higher surgical level of experience in LA leads to a shorter operating time, especially in complicated appendicitis which can need hand touching 6 . Intra-operative complications like Iatrogenic bowel injury and bleeding could not be managed laparoscopically, and mostly lead to open conversion 16 .
This study had concluded to independent factors of conversion: advanced age, Alvarado score 11 , high CRP value, and intraoperatively findings such as retrocecal appendix, perforated appendicitis, and appendicular abscess.

CONCLUSIONS
Laparoscopic appendectomy is a minimally invasive procedure that has become recommended as a standard technique for routine appendicitis, resulting in a better cosmetic outcome, and a shorter recovery time. Conversion from LA to OA procedure is done for more than one reason. Preoperatively, it is possible to identify predictive factors for conversion to laparotomy, and the ability to identify these reasons of conversion can aid surgeons in selecting patients who would benefit from a primary open appendectomy.